As I mentioned in my last post, neck and shoulder pain are among the most common reasons for clients to seek out massage therapy. In a perfect world, we would be able to engage in a wider variety of movements as well as getting in MORE movement throughout the day, including dynamic stretching. Recruiting all of the muscles in non-repetitive ways is easier on the body and should keep musculoskeletal complaints to a minimum. However, this is not always possible. Sometimes we just need simple stretches or exercises to help us “do the best we can”, since we spend too much time in one static position given our biomechanical environment. It is worth repeating that there is no “ideal” posture, but some postures are much easier on the body than others. Particularly in the case of forward head posture, alignment does matter. Barring injuries and other acute situations, the majority of us with just the standard discomforts due to forward head posture could benefit from three basic concepts:
a) getting the head aligned over the neck (not in front of it),
b) stretching the anterior musculature, and
c) strengthening the posterior musculature.
There is obviously A LOT more to consider, but these little basics are a great start. I have already written about getting the head on the neck and stretching the muscles in the chest and on the anterior part of the shoulder blade. The next step is strengthening the muscles in the back of the neck and shoulders that are being pulled taut and causing discomfort, specifically the rhomboids and the upper trapezius. This will be a two part blog post – the first will address the rhomboids and the second will address the upper trapezius. I will give some basic suggestions, but please CONSULT WITH AN EXERCISE PROFESSIONAL prior to trying any of these exercises if they are new to you or if you have injuries.
RHOMBOIDS: ANATOMY & PHYSIOLOGY
The rhomboids are a set of four muscles (two on each side) in the mid-back. They lie deep to the trapezius muscle, but not as deep as the erector group running along each side of the spine. Rhomboid major and minor together originate on vertebrae C7-T5 and the bottom of the ligamentum nuchae in the neck and insert on the medial edge of the scapula.
In other words, they connect the shoulder blade to the spinal column. Together they are responsible for stabilization, retraction, elevation and inward rotation of the scapula. The shoulder blade needs the ability to be stable with reference to the spine in all different planes of motion, as it is the anchor for many of the muscles that move the arm. For the same reason, however, it also needs the ability to perform fluid movement. In addition, as the arm moves, it needs room in the shoulder socket for the head of the humerus, or arm bone, to move. In order for the room to be created, the scapula, the coracoid process of the scapula (the bony protrusion of the shoulder blade in front of the shoulder) and the clavicle must all move together in a seamless motion. Needless to say, there is a lot going on in the shoulder girdle!
There are fifteen other muscles all attached to the scapula, in addition to the rhomboids, with lines of pull in all different directions. Given the main movements and postures that most of us engage in, the rhomboids often end up acquiescing to the “hunch club” we discussed before: pectoralis minor and subscapularis. This can put the rhomboids in a perpetual eccentric contraction (ie “putting on the brakes”) and make them overstretched, which is why so many of us have discomfort there. We think of them as being “tight”, but I think that word implies contracted or “the opposite of loose”, which is not quite right. Really the muscles are often “taut”, which is more like being pulled to the point of weakness. (I have my good friend, Ed Buresh, to thank for helping me find a better word to explain this.) Given that these muscles are overstretched, stretching them out is not very helpful. What really helps is strengthening them! Here are a few basic exercises to strengthen the rhomboids, but there are many variations that work and switching it up is always the best medicine – ask your personal trainer which exercises are best for you. As with every exercise, make sure your core is stable and you are not holding your breath (general rule: exhale on exertion).
BAND PULL-APARTS
This is a great exercise and is easy to do, even when traveling, as all you need to have with you is a band. The bands range from “easy” to “this-thing-barely-moves-it’s-so-hard”, so you can do this exercise whether you are a novice or a serious athlete. You simply start by holding the band out in front of you, as in photo (A). Slowly pull the band apart using your rhomboids until your arms are out to the sides, as in photo (B). Work your way up to two to three sets of fifteen repetitions, with rest or different exercises in between. Some things to keep in mind:
1. Arms should be straight. If the arms start to bend, your band is too tight – try a looser one to start.
2. Shoulders should remain relaxed and down. Again, if your shoulders are hunching, you are not maximizing your rhomboids. You can either do it in front of a mirror (what my trainer forced me to do), so you can correct your shoulders if they start sneaking up, OR start with an easier band.
There is no shame in starting with the lightest band – we have to meet ourselves where we are NOW, not where we were when we were marathon running (note to self), and not where we secretly want to be. Part of this whole process is seeing if we can get our bodies comfortable and mobile again after probably a lifetime of discomfort and immobility. This takes time to do safely. I always revert to writing in “we” form when not giving specific “instructions” (for lack fo a better word) because I am in this process, too! “Progress not perfection” is something I repeat to myself at least once a day but often more. It helps 🙂
3. The form in the photo shows the arm in medial or inward rotation, which is how we normally are, with subscapularis contracted. In order to stretch subscapularis and strengthen the lateral rotators (infraspinatus and teres minor) instead, you can do the 2.0 version: this involves changing your hand placement so the palms are facing each other and thumbs up, or even having the palms slightly up and the thumbs slightly out to the sides. This way as you pull out, you are in lateral rotation instead.
4. Don’t forget your breathing.
REVERSE FLYES
There are various ways to do this one, but this is the most comfortable for me. You hinge at the hips, with the back straight, arms down in front of you holding weights (as in the faded part of the above photo). You lift the arms straight out to the sides, contracting the rhomboids, until they are at shoulder level. Work your way up to two sets of twelve repetitions, with rest or different exercises in between. Some things to keep in mind:
1. Make sure you are in a proper hip hinge with your back straight. There should not be any flexion in your thoracic spine (in other words, the back should not be bent over in the middle). The head should be comfortable and neutral, eyes focused on a point on the floor in front of you. If you need to look up into the mirror in front, do so for one rep, but then make sure to put your head back into neutral position.
2. That said, there shouldn’t be too much extension or arch in the back, either. You need to be forward enough to actually engage your mid-back; otherwise, you are engaging the wrong muscles. In other words, it’s NOT this (see the area in yellow? That’s mainly the middle deltoid that is being worked here, not the rhomboids):
3. There are many variations you can do: with different objects (although the objects should be heavy enough to feel challenging after twelve reps), with bands or on an incline bench if that’s more comfortable for the back. See the photos below.
4. Don’t forget your breathing.
ROWS
Rows target multiple muscles, including rhomboids, and can be done seated or standing.
The seated row (photos above): begin by sitting on the bench and grasping the cable grip attachment. Sit upright, straighten your lower back and slide your hips back slightly. As you pull the attachment toward your waist, pull your shoulders back and squeeze your shoulder blades together. Hold that squeeze for an extra second to activate the rhomboids more specifically. Work up to three sets of twelve repetitions, with rest or different exercises in between. Remember to keep your back straight and to breathe.
The bent-over dumbbell row (photos above): Set up in the same manner as you would for the reverse flyes above. You can hold the weights with palms facing one another or palms up as in the photo above. Rather than moving arms out to the sides as in the reverse flyes, for this exercise you simply bend your elbows and pull your arms straight back until your wrists are at your sides. In order to activate the rhomboids more specifically, squeeze the shoulder blades together at the top of the movement and hold for an extra second. Work your way up to three sets of twelve repetitions, with rest or different exercises in between. Remember to keep your back straight, head neutral and breathe.
In the next post, we will highlight the upper trapezius muscle, another muscle which often gives people discomfort. Like the rhomboids, there is great evidence suggesting that strengthening rather than stretching this muscle leads to relief. Stay tuned 🙂
**BONUS EXERCISES**
FOR THE ATHLETES OR PEOPLE WORKING WITH TRAINERS (ONLY):
T-BAR ROWS
My trainer used to love this one – mostly for latissimus dorsi and teres minor, but it works the rhomboids as well. Please do not try this exercise for the first time without a trainer. Again, it’s a hip hinge with the back straight. This time the angle of the back to the floor is slightly larger, so you are able to look forward with the head still in neutral. The weight is shifted back onto the glutes. Start in the position in the first photo with the bar on the ground, and lift until the bar is at your chest as in the second photo. As you lift, your upper body lifts slightly as well (notice the difference between her body placement in the two photos). The great thing about this exercise is that it works many of the posterior chain muscles from back to legs.
BENT OVER BARBELL ROWS
This is another good one to work many of the muscles in the back. Again, please do not try this one for the first time without a trainer’s supervision. You can do it with a backwards grip or split grip, but I like the palm-forward grip like in the photo. Again, you hinge slightly at the hips, keeping the back straight and head in neutral.
Neck and shoulder pain are among the most common complaints reported by new clients. Recent developments in pain science have largely debunked purely structural models as explanations for pain. However, structural analysis is still relevant as a piece of a larger paradigm, particularly when it comes to the neck and shoulders. So while biomechanics may not be everything, in most cases of neck and shoulder complaints, consistent forward head posture greatly contributes to the root cause of the pain. In some of these cases, there is an accompanying uncomfortable “dowager’s hump” at the base of the neck that forms when the vertebrae become compressed. Neurological overstimulation can also result from sustained tension in the 
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